Healthcare Provider Details

I. General information

NPI: 1063968238
Provider Name (Legal Business Name): JUSTIN BEYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GUERRANT ST # 2242
UMATILLA FL
32784-8609
US

IV. Provider business mailing address

519 ELMWOOD RD N
MARLTON NJ
08053-5503
US

V. Phone/Fax

Practice location:
  • Phone: 609-685-3973
  • Fax:
Mailing address:
  • Phone: 609-685-3973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-12514
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: